JOHCD � www.johcd.org � May 2010;4(2)48

Pregnancy Associated

Gingival Enlargement

case

report

Anoop Kapoor, Ranjan Malhotra, Vishakha Grover, Divya Saxena

ABSTRACT

In this report, we present a case of gingival enlargement related to pregnancy causing chewing,

speaking, breathing and cosmetic problems. The patient was a 23-year old woman in the

eighth month of her first pregnancy, with localized gingival enlargement affecting both buccal

and lingual aspects of the area between right maxillary lateral incisor and canine. Hormonal

changes occurring during pregnancy have long been known to be associated with generalized

or localized gingival enlargements. Pregnancy does not cause the condition but altered tissue

metabolism in pregnancy accentuates the response to the local irritants.

KEYWORDS

Pregnancy, Gingival enlargement, Altered tissue metabolism

INTRODUCTION

Gingival enlargement is a common

clinical entity, but finds a unique

place in literature, because it has

been associated with a variety of local and

systemic factors so differential diagnosis

becomes an important aspect for complete

management of the lesion. Most of the

causative factors lead to an unusual

hyperplastic tissue response to chronic

inflammation associated with local irritants

such as plaque, calculus or bacteria (1).

Dr. Anoop KapoorE Mail: dranoopkapoor@rediffmail.comContact AuthorJ Oral Health Comm Dent 2010;4(2):48-51

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Hormonal changes occurring during pregnancy and

puberty, however, have long been known to be associated

with varying types of gingival enlargement. Hormonal

changes can significantly potentiate the effects of local

irritants on gingival connective tissue (2). In all forms of

enlargements, good oral hygiene is necessary to minimize

the effects of systemic factors, Gingivoplasty or

Gingivectomy may be required, but should be done in

combination with prophylaxis and oral hygiene

instructions(3). Lesions that do not cause significant

functional or esthetic problems should not be excised

during pregnancy because, first, they may reoccur and,

secondly they may resolve spontaneously post-partum (2).

This paper presents a case report of a typical pregnancy

associated gingival enlargement.

CASE REPORT

A female patient of 23 years age reported to the

Department of Periodontics, National Dental College &

Hospital, Dera Bassi, with localized gingival overgrowth

around the corner tooth on right side of upper jaw.

There was no history of drug intake and hereditary reasons.

Patient was eight months pregnant and revealed that her

gums used to bleed on brushing since three months of

pregnancy, but the enlargement came to the present size

at this time. She had consulted a local dental surgeon, who

gave her a fear of cancer of mouth in this region.

On examination, there was slight elevation of upper lip

due to presence of enlargement. Intraoral examination

showed enlargement encroaching between teeth 12 and

13, and extending from facial to lingual side, measuring

about 1.5 X 1.5 cm on palatal side (Figure1). Lesion was

bright red in colour, soft and bleeds on slightest

provocation. Surface appeared to be ulcerated on palatal

side. Subgingival calculus and plaque were present. Patient

was unable to maintain oral hygiene in this area, because

of gingival enlargement, rest of the oral cavity showed

normal gingiva and satisfactory oral hygiene.

Oral prophylaxis was performed after routine

haematological investigation. Instructions regarding

maintenance of oral hygiene were given. She was advised

to visit the department after parturition. Patient reported

one month after an uneventful first pregnancy.

Enlargement had slightly reduced and colour also changed

from bright red to reddish pink.

OPG was taken and the radiograph revealed slight crestal

bone loss in interdental areas. After reduction in

inflammation, lesion was excised along with raising of

periodontal flap in area of 12, 13 and open curettage of

area was performed. Excised lesion was sent for

histopathological examination, which revealed epithelial

proliferation and underlying capillary proliferation along

with marked inflammatory cell infiltration seen in

Figure: 1 Preoperative Photograph ShowingLocalized Gingival Enlargement

PREGNANCY ASSOCIATED GINGIVAL ENLARGEMENT

Fig 2: Postoperative Photograph Showing HealthyGingiva After Six Months.

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connective tissue. Early healing was uneventful as patient

reported after one week for suture removal. Patient

reported opening of interdental space. Patient was

reinstructed for maintenance of oral hygiene.

After six months postoperatively gingival contour was

normal and patient was able to maintain her oral hygiene

and there was no recurrence of the growth. (Figure 2)

DISCUSSION

Gingival changes in pregnancy were described as early as

1898, even before knowledge about hormonal changes was

available.

Gingivitis in pregnancy is caused by bacterial plaque, like

in non-pregnant individuals. Pregnancy accentuates the

gingival response to plaque. The correlation between

gingivitis and the quantity of plaque was greater after

parturition than during pregnancy, which suggests that

pregnancy induces other factors that aggravate gingival

response to local irritants.

Incidence of gingivitis in pregnancy varies from around

50% to 100% (Maier & Orban 1949) (3). Pregnancy does

not alter healthy gingiva; it affects the severity of previously

inflamed area. In the present case patient also had the

history of bleeding gums before pregnancy (4). Cohen et

al (1971) reported that there was partial reduction in the

severity of gingivitis two months post partum and after

one year the condition of the gingiva is comparable to

that of patient who has not been pregnant. In some cases

the inflamed gingiva forms a discrete mass referred to as

pregnancy tumor.

Kornman & Loesch (1980) have reported that the

subgingival flora changes to a more anaerobic flora as

pregnancy progresses (5). Prevotella intermedia is the only

microorganism that increases significantly during

pregnancy. They also stated that the increase is due to

elevations of levels of systemic estradiol and progesterone.

O’Neil (1979) suggested that the altered tissue response

to plaque is due to depression of the maternal T-

lymphocyte (6).

Formicola & Associates (1970) have shown that gingiva is

a target organ for female sex hormones (7). Radioactive

estradiol injected into female rats appears in the genital

tracts and the gingiva.

Therefore, the maintenance of oral hygiene before and

during pregnancy is very important in order to reduce the

incidence and the severity of gingival inflammation.

It is generally accepted that increase in gingival

inflammation typically begins in the second month and

reach the maximal level during the eighth month of

pregnancy (2, 8, 9). These inflammatory changes may lead

to gingiva that appears edematous, hyperplastic and

erythematous; the changes may be localized or generalized,

and are usually noted on the marginal gingiva and

interdental papilla. Gingival enlargement does not occur

without clinical evidence of local irritation. Pregnancy does

not cause the condition, but the altered tissue metabolism

in pregnancy accentuates the response to local irritants (10).

SUMMARY & CONCLUSION

The local factors i.e. plaque and calculus are known to be

responsible for gingival enlargement during pregnancy. The

hormonal factors also play a role in aggravating the

hyperplasia. Therefore, the importance of regular check

up and oral prophylaxis cannot be overlooked.

In all forms of gingival enlargements, good oral hygiene is

necessary to minimize the effects of systemic factors.

Although spontaneous reduction in the size of gingival

enlargement commonly occurs following childbirth,

complete elimination of residual inflammatory lesions

requires the removal of all forms of local irritants(2). In

the present case, size of the hyperplastic tissue was reduced

but the mass was still interfering with the patient’s ability

to chew, speak and was causing serious esthetic problems

so it was excised completely one month after delivery.

REFERENCES

1. Regezi JA, Sciubba J (eds): Oral Pathology, Clinical-PahologicalCorrelations, 2nd edition. Philadelphia; WB Saunders. 1993; pp196-202.

2. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis.Oral Surg Oral Med Oral Pathol 1991;72:196-199.

3. Maier AW, Orban B. Gingivitis in Pregnancy. Oral Surg 1949;2:234.4. Cohen DW, Shapiro J, Friedman L, et al. A longitudinal investigation

of the periodontal changes during pregnancy and fifteen months

PREGNANCY ASSOCIATED GINGIVAL ENLARGEMENT

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post partum. J periodontal 1971;42:653.5. Kornman KS, Loesch WJ. The

subgingival microbial flora duringpregnancy. J Perio dont Res 1980;15:111.

6. O’Neil TCA. Maternal T-lymphocyteresponse and gingivitis in pregnancy. JPeriodontal 1979;50:178.

7. Formicola AJ, Weatherford T, Grape H Jr.The uptake of H3-estradiol by oral tissuesin rats. J Periodontal Res 1970;5:269.

8. Gracia RI, Henshaw MM, Krall EA.Relationship between periodontal disease

and systemic health. J Periodontol2000;25:21-36.

9. Tilakaratne A, Soory M, Ranasinghe AW,Corea SMX, Ekanayake SL, De Silva M.Effects of hormonal contraceptives on theperiodontium, in a population of rural SriLankan women. J Clin Periodontol2000;27:753-757.

10. Abberitg G, Sigurdson A. Hyperplasticlesions of the gingival and alveolarmucosa. A study of 175 cases. ActaOdontol Scand 1983;41:75-86.

Dr Anoop Kapoor Reader,

National Dental College

Dera Bassi, Punjab

Dr. Ranjan MalhotraProfessor & HOD,

National Dental College

Dera Bassi, Punjab

Dr. Vishakha GroverAssociate Professor,

National Dental College

Dera Bassi, Punjab

Dr. Divya SaxenaPost Graduate Student

National Dental College

Dera Bassi, Punjab

THE AUTHOR